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High-risk foot (Diabetes and Endocrinology)

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Adult conditions

Pancreatic disease

  • Diabetic ketoacidosis  - A
  • Diabetes and severe vomiting -A
  • Acute severe hyperglycaemia
  • Acute severe hypoglycaemia -A
  • Hyperosmolar hyperglycaemic state (HHS) -A
  • Newly diagnosed type 1 diabetes –B (call registrar or consultant on call)
  • Foot ulcer with infection and systemically unwell or febrile -A
  • Invasive infection or rapidly spreading cellulitis of the foot (defined by peripheral redness around the wound >2cm) -A
  • Acute foot ischaemia -A
  • Wet gangrene foot -A

Urgent cases – (refer to key below)
A – client to present to emergency department immediately
B – client to present to diabetes specialist service within 24 hours.  If no specialist service is available, present to an emergency department.

High Risk Foot

  • Foot ulcer with infection and systemically unwell or febrile
  • Invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm)
  • Acute ischaemia
  • Wet gangrene
  • Acute or suspected Charcot

Thyroid disorders

  • Hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
  • Neutropenic sepsis in patient taking carbimazole or propylthiouracil
  • Hyperthyroidism with hypokalaemia or paralysis
  • Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)
  • Stridor associated with a thyroid mass
  • Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

Adrenal disease

  • Addisonian crisis
  • Suspected or confirmed acute adrenal insufficiency
  • Phaeochromocytoma in crisis with uncontrolled hypertension
  • Malignant hypertension

Pituitary disorders

  • All patients with visual field loss (usually temporal and classically bitemporal superior quadrantinopia/hemianopia)
  • Pituitary tumour with severe headache
  • Pituitary tumour with evidence of symptomatic cortisol insufficiency
  • Hyperprolactinaemia with visual impairment or other neurological signs

Oligo/amenorrhoea, hirsutism, acne, female infertility

  • Signs in the central nervous system that could indicate a pituitary tumour (visual field defect headaches)

Calcium, electrolyte and metabolic bone disorders

  • Acutely symptomatic hypocalcaemia (e.g. tetany) with serum calcium <2.0mmol/L
  • Severe symptomatic hypercalcaemia (usually serum calcium > 3.0 mmol/l)
  • Hypernatraemia or hyponatraemia with acute confusion/delirium
  • Suspected or confirmed diabetes insipidus with hypernatraemia

Paediatric Conditions

Paediatric diabetes

  • New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
  • Ketoacidosis in a known diabetic with any of the following
    • systemic symptoms (fever, lethargy) or
    • vomiting or
    • inability to eat (even if not vomiting) or
    • abdominal pain or
    • headache

Growth failure

  • Suspected pituitary mass (visual field loss/CNS signs)
  • Addisonian crisis (including unexplained hyponatraemia & hypoglycaemia)
  • Myxoedema coma
  • New onset diabetes insipidus (including unexplained hypernatraemia)
  • Hypocalcaemia (including acute rickets) with seizures

 

  • Refer to local Healthpathways or local guidelines
  • For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:
    • when diabetes is diagnosed, and at least annually thereafter
    • if any foot problems arise
    • on any admission to hospital, and if there is any change in their status while they are in hospital
  • For low risk of developing a diabetic foot problem, continue to carry out annual foot assessments, emphasise the importance of foot care, and advise they could progress to moderate or high risk
  • Basic foot care advice and the importance of foot care
  • ATSI people with diabetes are considered to be at high risk of developing foot complications until adequately assessed otherwise
  • Commence antibiotics as per therapeutic guidelines
  • Off-loading (This is a link to CSDC eLearning courses)
  • Advance health directive could be considered in patients with vascular disease
  • Renal impairment increases the risk of amputation for people with diabetes who experience amputation rates 11 times that of the general diabetic population, which in turn is 15 times the rate in people without diabetes


Examine both feet for evidence of the following risk factors:

  • Neuropathy (use a 10 g monofilament as part of a foot sensory examination)
  • Limb ischaemia (see CPC on peripheral arterial disease)
  • Ulceration
  • Callus
  • Infection and/or inflammation
  • Deformity
  • Gangrene
  • Charcot arthropathy

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Refer directly to emergency - Foot ulcer with infection and systemically unwell or febrile, invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm), acute ischaemia, wet gangrene, acute or suspected Charcot - A
    • Foot ulcer or pressure injury with mild to moderate infection <2cm around wound. - B
    • Necrosis/dry gangrene (with or without ulceration) - B
    • Non-infected foot ulcer.  For optimal care, a patient with an ulcer will be reviewed within 48 hours by a specialist High Risk Foot Service

     

    Urgent cases – (refer to key below)
    A – client to present to emergency department immediately
    B – client to present to diabetes specialist service within 24 hours.  If no specialist service is available, consult with a specialist service via telehealth, or present to an emergency department.

  • Category 2
    (appointment within 90 calendar days)
    • Diabetic with high-risk foot*
    • Peripheral arterial disease, peripheral neuropathy or foot deformity in the absence of adequate community resources

     

    *High-risk foot has 2 or more of the following:

      • Peripheral Neuropathy (PN),
      • Peripheral Arterial Disease (PAD),
      • Foot deformity

     or a history of:

      • previous amputation or
      • previous foot ulceration
  • Category 3
    (appointment within 365 calendar days)
    • No category 3 criteria

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

 

 

2. Essential referral information Referral will be returned without this

  • Details of all treatments offered and efficacy
  • Peripheral pulses, femoral/popliteal/foot

3. Additional referral information Useful for processing the referral

  • Is the ulcer neuropathic or ischaemic (or both) in origin?
  • Is there active infection? Consider deep wound swab/pathology for culture, ESR, CRP, FBC
  • Is there invasive infection with spreading cellulitis around the wound?
  • Is there bony infection? XR if required.
  • If suspected arterial disease –Doppler Ankle Brachial Pressure Index (ABPI), toe pressures, duplex scan etc
  • Appropriate medical history including claudication distance, rest pain, ischaemic changes and risk factors
  • Results of depression screening (PHQ-2)
    • over the last 2 weeks, how often have you been bothered by any of the following problems?
      • little interest or pleasure in doing things?
      • feeling down, depressed, or hopeless?

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.